Virtual Meeting Clip
In India, a country where basic resources and access to preventive medicine are scarce, ordinary vinegar holds promise for saving thousands of women from dying of cervical cancer—the most common and most deadly cancer among Indian women.
Findings from a randomized, controlled trial conducted among 150,000 women in Mumbai slums over a 15-year period show that biennial screening for cervical cancer by trained nonmedical personnel using acetic acid reduced cervical cancer mortality by 31% (Abstract 2). If implemented in developing countries that have little or no access to Pap screening, this easy-to-use procedure could ultimately prevent 22,000 deaths from cervical cancer in India and 72,000 deaths in low-resource countries worldwide each year, according to Plenary Session Presenter Surendra S. Shastri, MD, of the Tata Memorial Hospital, India.
“The goal of a cervical cancer prevention program in…developing countries really is to maximize participation and use tests that have maximum sensitivity, affordability, and feasibility,” Discussant Electra D. Paskett, PhD, of The Ohio State University Comprehensive Cancer Center, explained during Sunday’s session. Dr. Paskett commended Dr. Shastri for achieving this goal and stressed that the key take-home message from this study is that “visual inspection with acetic acid (VIA) is a validated, acceptable, cheap, implementable, generalizable screening tool. It can be used in low-resource countries and it can save lives.”
Overcoming Infrastructure, Financial Obstacles
The burden of cervical cancer weighs heavily in resource-limited settings, largely a result of lack of screening programs. Nearly 142,000 cases of cervical cancer occur each year in India alone, and annually more than 77,000 Indian women die of the disease. When viewed from a global perspective, these figures account for approximately 30% of the burden of cervical cancer worldwide.
Whereas Pap smear screening for precancerous cells has cut cervical cancer incidence and mortality by 80% in high-income countries, large-scale Pap screening is simply not feasible in India. In 1992 and again in 2006, the government determined that inadequate infrastructure, lack of trained personnel, logistic difficulties, and the relatively high cost of the procedure pose too great a drain on restricted resources.
A Viable Solution
VIA is a simple, rapid, inexpensive test that offers a practical alternative to Pap smears or HPV DNA testing in resource-limited settings. Sixty seconds after applying vinegar to the cervix
using a cotton swab, precancerous lesions turn white and can be discerned from pink healthy tissue with the naked eye—something that primary health workers can easily be trained to identify with high accuracy.
Given these advantages, “VIA is a technique that can be used in the lowest-resource settings in countries like India,” Dr. Shastri said.
Dr. Shastri and colleagues sought to evaluate the feasibility of using VIA as a large-scale screening program for reducing cervical cancer mortality in India. The investigators initiated a randomized controlled trial in 1998 among 151,538 women age 35 to 64 in Mumbai slums who had no prior cancer history. One-half of the women were randomly assigned to receive four rounds of cancer education and VIA every 24 months, whereas the other one-half received no screening—the current standard of care in India—and one-time cancer education at recruitment.
All women in the screening group who tested positive by VIA, and those in the control group who noticed signs or symptoms of cervical cancer taught to them at enrollment, were directed to Tata Memorial Hospital or other facilities for diagnosis. Those with confirmed disease received free cervical cancer treatment.
Invasive cervical cancer occurred at a similar incidence in the screening and control groups (26.74 and 27.49 cases per 100,000 women-years of observation, respectively), demonstrating no overdiagnosis from screening. “This is a crucial factor in low-resource settings where the public health systems are already overburdened,” Dr. Shastri emphasized.
VIA enabled diagnosis at an earlier stage of the disease and hence earlier treatment, which translated into survival gains. Use of VIA significantly reduced the rate of cervical cancer mortality from 16.22 to 11.12 deaths per 100,000 women-years of observation (p = 0.003) —a 31% reduction compared with the control group. All-cause mortality also fell by 7% in the screening group compared with the control group, from a rate of 873.01 to 814.51 deaths per 100,000 women-years of observation, although this change was not statistically significant (p = 0.406).
Instead of having to rely on physicians and nurses, the screening exams were carried out by primary health workers trained to perform VIA in only 4 weeks. These were local women with at least a 10th-grade education and good communication skills. Dr. Shastri noted that an expert gynecologist randomly rescreened approximately 5% of participants using the VIA technique, confirming excellent agreement with the findings of the trained nonmedical personnel
(kappa = 0.84).
Although study follow-up is still ongoing, Dr. Shastri has immediate plans to begin to implement VIA screening more broadly. “We are already working with state and national health authorities in India to make this screening strategy available to women throughout the country,” Dr. Shastri told ASCO Daily News.